A coalition of civil society organizations and academics are initiating a
Joint Action and Learning Initiative on National and Global
Responsibilities for Health (JALI) to research key conceptual questions
involving health rights and responsibilities, with the goal of securing
a global health agreement and supporting civil society mobilization
around the human right to health.
This agreement—such as a Framework Convention on Global
Health—would inform post-Millennium Development Goal (MDG) global
Using broad partnerships and an inclusive consultation process, JALI
seeks to clarify the health services to which everyone is entitled under
the right to health, the national and global responsibilities for
securing this right, and global governance structures that can realize
these responsibilities and close major health inequities.
Mutual benefits to countries in the Global South and North would come
from a global health agreement that defines national and global health
JALI aims to respond to growing demands for accountability, and to create
the political space that could make a global health agreement
A decade into the 21st century, billions of people have yet to benefit from the
health advances of the 20th century. Life expectancy at birth in sub-Saharan Africa
is 53 years —only two years higher than in the United States a
century ago ,
and 27 years lower than in high-income countries today . The most basic human needs
continue to elude the world's poorest people. In 2010, approximately 925
million people were suffering from chronic hunger , 884 million people lacked access
to clean water, and 2.6 billion people were without access to proper sanitation
Such global health disparities will likely persist until there is fair and effective
global governance for health—the organization of national and global norms,
institutions, and processes that collectively shape the health of the world's
population. Global governance for health goes beyond the health sector. It requires
remediating the currently unfair and detrimental health impacts of international
regimes (e.g., trade, intellectual property, and finance), and developing stable,
responsive, democratic political institutions.
A coalition of civil society and academics, with a shared vision of the “right
of everyone to the enjoyment of the highest attainable standard of physical and
mental health”  (“right to health”), is therefore launching
the Joint Action and Learning Initiative on National and Global Responsibilities for
Health (JALI). JALI seeks to develop a post–Millennium Development Goal (MDG)
framework for global health, one rooted in the right to health and aimed at securing
universal health coverage for all people. We seek to clarify the health goods and
services to which all people are entitled, national and global responsibilities to
secure the health of the world's population, and governance structures required
to realize these responsibilities. Our goal is a global agreement, such as a
Framework Convention on Global Health, which sets priorities, clarifies national and
international responsibilities, ensures accountability, and develops corresponding
institutions, such as a Global Health Fund ,.
Partnerships with Civil Society Organizations
JALI will draw inspiration from, and collaborate with, civil society movements, which
are central to securing and ensuring adherence to a global health agreement. Such
movements have spurred momentous transformations in health. Advocates changed the
world's response to AIDS from one marked by discrimination to one focused on
empowering marginalized people and scaling up HIV services. The Campaign to Ban
Landmines drove a process that culminated in a treaty banning this indiscriminate
Civil society campaigns for the right to health, such as those through the
People's Health Movement, are already underway . Nongovernmental organizations
(NGOs) from the South and North launched a Declaration of Solidarity for a Unified
Movement for the Right to Health . JALI is developing the partnerships required to undertake
an inclusive process involving research, analysis, and extensive online and regional
consultations to gain insight into and build consensus around answers to four
foundational questions, and to stimulate coordinated action to reduce health
inequities. This bottom-up, research-focused process will develop a detailed
understanding of health rights and state obligations, clear targets and benchmarks
for success, and effective monitoring and accountability mechanisms. These will add
precision to and enhance the effectiveness of international human rights law, which
could in turn enhance civil society efforts to hold their own governments to
account. By drawing on the voices of civil society and disadvantaged communities,
JALI could have the legitimacy and the political support to transform global
governance for health.
Four Defining Questions in Global Health
The four defining questions, and preliminary directions on answers, are:
1. What are the services and goods guaranteed to every person under the human
right to health?
The World Health Organization (WHO) has placed universal health coverage high on the
global health agenda , defining three dimensions of coverage: 1) the proportion
of the population served; 2) the level of services; and 3) the proportion of health
costs covered by prepaid pooled funds . WHO has defined universal
coverage “as access to key promotive, preventive, curative and rehabilitative
health interventions for all at an affordable cost” .
The human right to health, an international treaty obligation, provides critical
insight into how states should work towards universal coverage (Figure 1). Core obligations offer benchmarks to
assess progress towards universal coverage, such as non-discrimination, equitable
distribution of health facilities, and essential services for all, including those
addressing underlying determinants of health .
The core principle of equality requires states to prioritize covering 100% of
their populations. Although 100% coverage of all health services will not be
possible immediately, full coverage of “key” health interventions should
be an initial benchmark towards universal coverage. The right to health framework
militates against a narrow definition of “key” services. Rather, these
should encompass WHO's health system building blocks (e.g., services,
workforce, information, financing, and governance); essential vaccines, medicines,
and technologies; and fundamental human needs (e.g., sanitation, nutritious food,
potable water, safe housing, vector abatement, tobacco control, and healthy
Critically, universal coverage should be re-conceptualized to encompass fundamental
human needs given their major impact on health. Within this framework, specific
services would be determined nationally through participatory processes .
The provision of each of these core entitlements—health systems, essential
vaccines and medicines, and fundamental human needs—should represent only one
significant step towards achieving the highest attainable standard of health.
States, even wealthy ones, will need to continue to progress towards universal
coverage. The right to health requires states to spend the “maximum
of…available resources” towards progressively realizing health and other
socioeconomic rights . Thus, under international law, states have a duty
“to move as expeditiously and effectively as possible towards” fully
realizing the right to health .
2. What responsibilities do all states have for the health of their own
The right to health places the primary responsibility on governments to ensure the
health needs of all their inhabitants. National responsibility includes health
sector funding, addressing the socioeconomic determinants of health, and good
There is no universally agreed level of health sector funding adequate to meet the
population's needs. African heads of state agreed to a benchmark of at least
15% of national budgets devoted to the health sector , and to allocating at
least 10% of their national budgets for agricultural development . Additionally,
32 African countries set a target, as an aspiration, to have public sector budget
allocations for sanitation and hygiene programs reach at least 0.5% of gross
domestic product .
These benchmarks set a minimum bar for national funding responsibilities, which
extend beyond the health sector. National health responsibilities should comply with
well-defined, measurable international standards, balanced against the flexibility
necessary to respect national priorities, health profiles, and needs.
States also have a responsibility to govern well, derived from central human rights
tenets such as participatory processes, transparent and accountable government, and
non-discrimination and equality. Well-designed legal rules and institutional
arrangements can facilitate honest administrations, openness, and accountability,
along with meaningful civil society and community participation in decision-making.
The law, moreover, should guarantee equality and non-discrimination on the basis of
race, sex, religion, disability, and other statuses. Measures to enhance
accountability to communities in India's National Rural Health Mission , and
Brazilian policies to reduce health disparities , offer instructive lessons.
3. What duties do states owe to people beyond their borders in securing
the right to health?
Resource-poor states lack capacity to ensure all of their people even core health
goods and services, much less a fuller realization of the right to health. Countries
in a position to assist are obliged to do so under principles of international law
and global social justice. The Committee on Social, Economic and Cultural Rights has
declared that cooperation towards realizing the right to health is “an
obligation of all States,” particularly those “in a position to assist
others” ,. All countries have mutual responsibilities towards
ensuring the health of the world's most disadvantaged.
Beyond development assistance, coordination and coherence is required across sectors,
as global health can be improved or harmed through state and international policies
and rules that govern areas such as trade, intellectual property, health worker
migration, international financing, and debt relief. These responsibilities extend
to the exercise of state power and influence over multilateral institutions such as
the World Bank, International Monetary Fund, and World Trade Organization.
International aspects of the right to health are ill-defined. With limited
exceptions, such as the commitment of wealthy countries to spend 0.7% of
gross national product on official development assistance, health and development
commitments are framed collectively, vaguely, or not at all. Even when countries
make commitments, they often fail to follow through. For example, only one month
after countries at the 2010 United Nations (UN) MDG Summit committed to provide
“adequate funding” for the Global Fund to Fight AIDS, Tuberculosis and
Malaria, pledges at the replenishment conference fell billions of dollars short
,. The Summit
called for accelerated development assistance for health, though the rate of
increase in assistance dropped during the global recession ,. Budget shortfalls in the
aftermath of the financial downturn further threaten assistance levels.
4. What kind of global governance for health is needed to ensure that
all states live up to their mutual responsibilities?
Translating a shared understanding of national and global responsibilities into new
realities requires effective and democratic global governance for health.
Notwithstanding the Paris Declaration on Aid Effectiveness, global health faces
challenges of weak leadership, poor coordination, underfunded priorities, and a lack
of transparency, accountability, and enforcement .
Innovative global governance and enhanced funding would empower WHO to exercise
effective leadership in the health sector and persuasive advocacy on agriculture,
finance, and trade. Moreover, state policies (e.g., agricultural subsidies,
intellectual property, and foreign affairs) can powerfully affect health in
resource-poor countries. States, therefore, should adopt a
“health-in-all-policies” approach where all ministries address the
health impacts of their policies and programs. Effective governance must include
active citizen participation to ensure transparency, collaboration, and
accountability while maximizing creativity and resource mobilization by states,
international organizations, businesses, and civil society.
Most importantly, the global health architecture must hold stakeholders accountable,
with clear standards for success, monitoring progress, and enforcement—all of
which have been lacking. Lack of sufficiently precise obligations and compliance
mechanisms under the right to health hinders accountability, though promising
approaches exist. Human rights bodies and UN special rapporteurs are adding clarity
to state responsibilities under the right to health, which is required for
meaningful accountability, as are constitutional court decisions in Argentina,
India, and South Africa ,.
Innovations in human rights law and practice hold potential for greater
accountability. Regional right-to-health special rapporteurs could be established,
enabling more effective national engagement. An empowered human rights sector could
learn from international regimes with more vigorous adjudication and enforcement
mechanisms, such as trade. Actions to ensure that social movements and voters are
well-informed about their countries' commitments could strengthen political
The Global South, where most of the world's least healthy people reside, should
lead in shaping global governance for health policies, where community priorities
drive global action. New governance requires the full participation of, and support
for, marginalized populations.
Towards a Hopeful Future for Global Health
Why would states agree to greater accountability when so many countries fail to
adhere to existing commitments? We do not underestimate the gravity of the
challenge, yet JALI offers possibilities for success. Social mobilization could
ignite new possibilities, as the AIDS movement has done, unleashing the collective
power of health advocates and empowered communities.
The framework of mutual responsibilities that emerges from JALI should prove
attractive to both Southern and Northern governments, creating incentives to develop
a far-reaching global health agreement. Mutual responsibilities come with mutual
benefits. Southern countries will benefit from increased respect for their
strategies, greater and more predictable funding from more coordinated and
accountable development partners, reform of policies that harm health, such as those
in trade and agriculture, and most importantly, better health for their populations.
Countries in the North will benefit from increased confidence that development
assistance is spent effectively and the prospect of reduced financing needs over
time as host countries increase their own health spending and build sustainable
health systems. All will benefit from lessons on shared health challenges, from the
economic and educational gains that will come with improved global health, and from
increased protection for their populations from global public health
threats—and from mutual goodwill derived from participating in an historic
venture to make unprecedented progress towards global health equity.
This is also a moment of rare opportunity. The post-MDG global health framework is
yet to be developed. Demand for accountability is growing. The right to health is
increasingly motivating not only civil society, but also governments. The Pan
American Health Organization passed a resolution on health and human rights , and the UN
General Assembly explicitly recognized the right to clean water and sanitation . Universal
coverage, primary health care, and socioeconomic determinants are receiving renewed
focus. Global health remains prominent on the international agenda, evidenced by the
attention to global health and foreign policy and the upcoming UN high-level summit
on non-communicable diseases.
In January 2011, WHO's Executive Board called on the Organization to assume a
“more active and effective role” in “directing and
coordinating” international health activities . The agency initiated a reform
process to strengthen its “central role in global health governance”
,. JALI supports
WHO leadership, but also governance reforms extending beyond WHO, and even beyond
the health sector, for a deeper understanding of the multiple forms of injustice
that adversely affect health and development.
We invite readers to join JALI (http://www.section27.org.za/2010/11/23/jali) to develop widely
shared understandings of national and global responsibilities for health to inform
post-MDG commitments and create an innovative global agreement. It is time to
define—and to meet—these responsibilities.